Watching Trinidad, I was struck by the way in which the rationale for communal tolerance of trans women in Trinidad was so often reduced to the money they poured into the town’s economy. Several times during the documentary, we hear resident testimonial that runs along these lines: it would be misled to treat visiting and resident trans women with anything less than a limited tolerance given the fact that they are the reason our hospital is still open. In other words, the establishment of Trinidad as the ‘sex change capital of the world’ has created a booming surgical niche market that is keeping the health care industry in Trinidad afloat (this, although one resident mentions that the hospital only receives $2,000 from each procedure, the pricetag of which floats somewhere around $20,000).

What’s striking to me about this repeated assertion is the notion that the town’s economic bottomline dictates the affective responses of the citizens. We accept you, but only if you’re financially contributing. Trans tolerance (I’m pointedly not using the word “acceptance” here) has a price, in other words – and that price is somewhere in the ballpark of $20,000.

Which leads to another concern: the large out-of-pocket expense of transition, and genital reassignment surgery in particular. The Human Rights Campaign, as part of their yearly Healthcare Equality Index, had 122 top medical providers fill out a survey that addressed LGBT healthcare issues – partner visitation rights, sensitivity trainings, and the like. Only 12 respondents out of these queerly enlightened 122 service providers offered trans-inclusive benefits to their employees. That number, though, is significantly higher than in other industries. The HRC also publishes a Corporate Equality Index each year, with a special section on Transgender-Inclusive Benefits; the stats aren’t great. It turns out that, until the mid-1970s, genital reassignment surgery was often covered by insurance; then, as tsroadmap.com, an informational site for trans women, puts it,

a couple of medical articles came out in the late 1970’s showing high suicide rates among post-operative women. This came at the same time a couple of prominent gender clinics were closed, notably Johns Hopkins. The insurance companies pounced on these events as a chance to decry the procedure as elective, cosmetic, or experimental. It’s been an uphill battle since.

It is precisely these arguments that the HRC document responds to, framing GRS as a physically and psychologically necessary procedure that is safe, well-researched, and quite well-developed (an art, as Dr. Marci Bowers puts it).

The Jim Collins Foundation, a non-profit that assists trans folks in paying for gender-confirming medical procedures, has been established in order to fill the gaps in insurance coverage; this effort, while enormously well-intentioned and important, is not a big enough band-aid, I suspect. The real issues are employment discrimination and insurance discrimination. What matters is having enough money to pay for gender confirming procedures, having stable employment throughout transition, and having coverage that understands gender-confirming procedures as integral to health in a holistic sense; even limited research into the economic status of trans subjects reveals markedly high rates of poverty and financial instability.

So how do we begin to ameliorate this situation? What other efforts are currently underway to address this web of medico-socio-economic injustice? Consider these general question for the course.